Shobha S. Krishnan, M.D., is a Staff Physician at Columbia University's Barnard College Health Services. A board certified gynecologist and family practice physician, she has also worked as a surveillance physician for the federal Centers for Disease Control and Prevention. Prior to joining Barnard, she was in private practice for 10 years. In addition, Dr. Krishnan has worked as a physician at the Institute on Aging and as Chief Resident in the Family Practice Department at St.Vincent Hospital, Indianapolis. Her new book, The HPV Vaccine Controversy: Sex, Cancer, God and Politics- A Guide for Parents, Women, Men and Teenagers(Greenwood Publications, Aug '08), presents the most up to date information about the vaccine without the influence of pharmaceutical companies or other interest groups.

Shobha Krishnan--

If you have been up to date with the latest Human Papilloma Virus (HPV) news, you might have heard that Dr. Harald Zur Hausen, a German scientist who discovered the link between HPV and cervical cancer, was awarded the 2008 Nobel Prize for Medicine this year. HPV is the most common sexually transmitted virus, and cervical cancer is the most serious consequence of HPV infections. Additionally, the different strains of HPV cause many other cancerous and non-cancerous diseases beyond cervical cancer. The latest report from the CDC, “Assessing the Burden of HPV- Associated Cancers in the United States” and published in the November 15, 2008 supplement to the journal Cancer comprises the largest and most up to date assessment of HPV-related cancers in the United States between 1998 and 2003. The main purpose of the study was to get a better understanding of the broad spectrum of HPV related pre-cancers and cancers before the introduction of the HPV vaccine, Gardasil, in June 2006, and to study the future impact of the vaccine on these disease states.

Highlights of the report include:

• Number of HPV-related cancers: Approximately 25,000 per year
• Most common infection sites: Cervix, head and neck, anus, vulva, vagina and penis
• Most common reasons for HPV-related cancers: Low education and high poverty levels.
• Relationship among HPV-associated cancers: Those with cervical cancer had a higher chance of developing vaginal, vulvar and rectal cancer

The following are summaries of the report’s findings on different kinds of cancers caused by HPV

• Cancer of the cervix: The most common site of HPV-associated cancer, there were around 10,800 cases per year of cervical cancer during the study period. Blacks from the South, Hispanics form the Texas- Mexican border, Whites from the Appalachians and Asian immigrants were most affected. Low educational levels, and heightened poverty were cited as the causes. As a reference, according to The American Cancer Society, 4 out of 5 women who developed cervical cancer did not obtain a Pap test in the past 5 years.
• Head and neck: Even though the rates of head and neck cancers in this country have been declining since 1960s when the surgeon general issued a warning about the negative effects of smoking, certain cancers of the head and neck --particularly those of the tonsils, base of the tongue and back of the throat (the oropharyngeal region) -- have been steadily rising at about 3%-4% per year. This is linked to HPV infections from the rising frequency of oral-genital sex. Oral cancers are the second most common type of HPV-associated cancers, with nearly 7,400 occurring in the study period. Blacks, Non-Hispanics and men were most affected.
• Anal cancer: Anal sex is often seen as a taboo in our society because of its association with homosexuality, but even though gay and bisexual men are at a higher risk for developing anal cancer, there are a greater number of heterosexual and bisexual women engaging in anal sex than gay or bisexual men. Therefore, more women get anal cancer than men. According to this report, more than 3,000 HPV-associated anal cancers occurred per year – about 1,900 in women and 1,100 in men. Blacks and Hispanics were most affected.
• Vulvar cancer: Nearly 2,300 women developed vulvar cancer per year during the study. White women were most affected.
• Vaginal cancer: 600 women developed vaginal cancer per year during this study period. Blacks and Hispanics were most affected.
• Penile cancer: Penile cancers are rare in the United States. The causes, racial and geographic distribution of penile cancers parallel that of cervical cancers. According to this study, penile cancer strikes about 800 men per year.
• HPV Vaccine: The only HPV vaccine that is currently available in the U.S is Gardasil by Merck. The vaccine is indicated for the prevention of most genital warts and cervical, vaginal and vulvar cancer. It has not yet been approved for anal, penile, or mouth and throat cancers, nor has it been approved for men in this country. As the vaccine is preventive in nature, it is recommended for routine immunization in females between the ages of 11-12 (before sexual debut) with the possibility for catch up through 26 years of age.

Even though this study proves that the burden of HPV cancers is significant, several salient factors present themselves that need to be addressed in order to best combat HPV-related diseases. First, since most HPV-related cancers take decades to develop, it would take several years for us to effectively measure the true impact of the vaccine. However, precancerous lesions occur much earlier in the process, and it would therefore help to use them as surrogates to measure the potential success of the vaccine. Unfortunately, we do not have an organized system to track precancerous lesions in this country like we do a cancer, and therefore, the impact of the vaccine will not be measurable for years to come. Hence, the creation of a pre-cancer registry is highly recommended.

Second, the study has shown that cervical cancer and many other HPV-related diseases are a reflection of health care disparities that include socioeconomic differences, inadequate access to healthcare, and ethnically unsound public education. Health awareness programs should not only aim to educate but should also tailor their message in a culturally sensitive manner to cater to the needs of people from various backgrounds –an area where we should discriminate in order to maximize positive health outcomes.

The HPV Vaccine And Sexual Promiscuity

Over 99% of Cervical Cancer Caused By HPV

How Safe is Gardasil : The HPV “Hot Shot”?